Category Archives: Aviation

All aviation topics

Herald of Free Enterprise

Ships and Planes and Managers who don’t know!

Have you ever wondered if a pilot in command can learn safety lessons from a ship’s captain? The answer is unreservedly yes because the similarities between the two professions are remarkable. Both are in command. Both are ultimately responsible for the safety of their vessel, their crew, and to their passengers. And strangely enough in many cases they are working for people who are not experts in their profession. One of the requirements of a Safety Management System (SMS) is to define an accountable executive, he who controls the purse strings. How many pilots are working for pilots? For that matter, how many sea captains are working for sea captains? In both cases not many.

The historical lesson we can take from previous accidents in either field, whether in the air or on the sea, cannot be more clearly highlighted than by a study of the Herald of Free Enterprise Disaster. This was a roll-on roll-off ferry that capsized on 6 March 1987 causing the deaths of some 188

persons because it left port with the bow doors open. This was, as are many transportation accidents, a human error accident. The report into this accident (UK Department of Transport MV Herald of Free Enterprise Report of Court No. 8074, MV Herald of Free Enterprise) said, “At first sight the faults which led to this disaster with the aforesaid errors of omission on part of the master, the chief officer, and the assistant boatswain…” (Report paragraph 14.1) As usual, this is not the whole picture. Somewhat controversial for the time, the report’s authors created somewhat of a precedent of adding the cause, “Failure of Management“, to the list of causes. The most damning piece of the report is, “…all concerned in management, from the members of the board of directors down to the junior superintendents, were guilty of fault in that all must be regarded as sharing responsibility for the failure of management. From top to bottom the body corporate was infected with the disease of sloppiness.”


To best illustrate this failure of management the report examined in detail the consideration that had been given, at the request of the sea captains, to fitting an indicator system to show whether the bow doors were open or closed. The captain’s concerns were repeatedly documented and yet rejected for the reasons of costs or even trivial, sarcastic, and frankly incredible statements such as, “do not we pay somebody to close the doors?” Another management failure was the lack of clear orders for the crews and their officers. In short, nobody was actually ordered to close the doors. There was evidence that on many occasions the ships had been overloaded, that they sailed incorrectly ballasted and therefore unstable, and that these shortcomings had been drawn to the attention of management on many occasions by the captains.


So who were these captains working for? The report states, “… those charged with the management of the company’s fleet were not qualified to deal with many nautical matters and were unwilling to listen to their masters, who were well qualified.” Does this sound familiar to many a pilot? How many pilots work for management qualified to deal with aviation matters? Are not many aviation companies run by those with degrees in business, or accountancy, or almost anything except aviation? Surely this must lead to the same frustrations the ferry captains must have felt at the lack of action on serious concerns and other safety issues they had raised with management?


So is there a possible way to solve the issue of specialists working for layman? This whole story of the Herald of Free Enterprise was actually a pivotal point in the history of safety management. The introduction of safety management systems to the transportation industry in particular has many attractive features. Perhaps the most important has already been mentioned; the identification of the accountable executive. This defines, perhaps for the first time, the desk upon which Harry S Truman’s sign, “the Buck Stops Here,” must sit. Part of the measure of a safety culture is the attitudes and commitment of management toward safety; having committed to adopting SMS that attitude is by design subject to change.


So if we are truly to learn from this tragedy management must listen to those who are experts in their appropriate field, react to hazards identified by their experts, and prove that they really are committed to safety by their actions not by their words. Pilots can learn from this too, for they are in the best position to find hazards both in the air and on the ground. They only have themselves to blame if they do not report these hazards.


So has your organization recently adopted SMS? Have you had your Herald of Free Enterprise moment? Have you noticed your management responding more positively to your concerns than before?



Emergency AD: Eurocopter Deutschland GmbH (ECD) Model EC135 P1, EC135 P2, EC135 P2+, EC135 T1, EC135 T2, and EC135 T2+ helicopters

The FAA has issued an emergency Airworthiness Directive (AD) for the EC 135, all variants.

The European Aviation Safety Agency (EASA), which is the Technical Agent for the Member States of the European Union, has issued EASA AD No. 2012-0041-E, dated March 12, 2012 (2012-0041-E), to correct an unsafe condition for the ECD Model EC 135 helicopters. EASA advises that during an inspection of an EC 135 helicopter, a crack was detected on the lower hub- shaft flange of a main rotor hub (MRH) shaft. Since issuing 2012-0041-E, two other lower hub-shaft flange cracks have been reported. ECD is investigating the cause of the cracks and may issue a revised service bulletin with further corrective action. We are issuing this EAD to detect a crack on the hub-shaft flange, which if not corrected could result in failure of the main rotor hub and subsequent loss of control of the helicopter.

Emergency AD#: 2012-10-51

From Reuters

Limitations and Dangers of the use of the English Language in Aviation Communications

Limitations and Dangers of the use of the English Language in Aviation Communications

AVIA 300 Aviation Safety – Week Seven

John Kirk


This paper is an overview of the limitations and dangers of the use of the English language in aviation communications.  Although the internationally agreed language in the air has been English since 1951, there was little research into the safety implications of this policy. Later, after too many examples of accidents where language difficulties were factors, research took place. The major results of that research are examined. Examples of aircraft accidents where language difficulties were a factor are examined. Some examples of regional dialectic differences are highlighted. Finally conclusions and recommendations are listed.


The KLM/ Pan Am disaster at Tenerife airport (Los Rodeos) on March 27th 1977 was the worst accident in aviation history in terms of loss of life. A major contributory factor was the failure in communication using the English language. The KLM aircraft had taken off without take-off clearance, in the absolute conviction that this clearance had been obtained, which was the result of a misunderstanding between the tower and the KLM aircraft.

This misunderstanding had arisen from the mutual use of usual terminology, which gave rise to misinterpretation. In combination with a number of other coinciding circumstances, the premature take-off of the KLM aircraft resulted in a collision with the Pan Am aircraft, because the latter was still on the runway since it had missed the correct intersection.

International Agreement

One of the outcomes based on this and many other accidents and incidents was the introduction of Language Proficiency Requirements (LPR) by the International Civil Aviation Organization (ICAO) in 2004. ICAO grades English language performance on a scale from 6 (highest) to 1 (lowest):

Level 6:


Level 5:


Level 4:


Level 3:


Level 2:


Level 1:


Formal evaluation of language proficiency was required as of March 2008, but ICAO effectively extended the deadline to 5th March 2011. In the USA the Code of Federal Aviation Title 14 (CFR) Part 61 requires that pilots must be able to read, speak, write and understand the English language. This proficiency is recorded on a pilot’s license. The current FAA standards for English language proficiency are laid out in Advisory Circular AC 60-28, English Language Skill Standards reproduced at Appendix 2.

Testing Standards

Whilst the ICAO recommendations determines the standards to be achieved, there is little information available on the reliability and accuracy of testing methods. A survey of aviation English TESTS Alderson, (2010) states, inter alia, “We conclude that we can have little confidence in the meaningfulness, reliability, and validity of several of the aviation language tests currently available for licensure.” (P. 1) This raises considerable concern, as the lack of creditable standards for testing creates a shortfall in the intention in the ICAO document. See Appendix 1 for the standards to which testing should be directed.

Even native English speaking aviators and air traffic controllers must pass knowledge tests which include standard phraseology which must be included in their initial training. In the USA, check airmen are required to certify English proficiency per the Practical Test Standards (FAA). If there is any doubt, a candidate must be referred to an aviation safety inspector (ASI) at the local FAA Flight Standards District Office. In the United Kingdom, a signatory to the Joint Airworthiness Agreement, a similar requirement has been established with the major difference that there are two levels of testing, formal and informal. English Language Schools accredited to the English Council are nominated for formal examination for levels 5 and below, and UK CAA examiners and some others are accepted for level 6.

Specific Example of Dialectic and Foreign Speaking Difficulties

Mention has already been made of the Tenerif accident as perhaps one of the best examples of a non-native English speaker’s difficulty. The phrase “We are now at takeoff,” is the key to understanding the difficulties. In the pilot’s native Dutch, the present progressive tense of a verb is expressed by the word “at” in English plus the infinitive of the verb, “takeoff.” The obvious interpretations of that phrase are:

  1. “We are holding at the takeoff position,” (which is the meaning the Spanish speaking air traffic controller assumed,)
  2. “We are in the act of taking off,” i.e. actually moving.

It is the second meaning that the Dutch pilot assumed the controller understood. The ICAO recommendations address this specifically where level 4 proficiency assumes, “Basic grammatical structures and sentence patters are used creatively and are usually well controlled. Errors may occur, particularly in unusual or unexpected circumstances, but rarely interfere with meaning.” Clearly, a fuller understanding of English grammar, as opposed to word-for-word translation of another native language, is key to success as in this example.

Second Example, voice warning systems

On November 13, 1993, a McDonnell Douglas MD-82 jet crashed in Urumqi, China, while it was approaching to land, killing 12 and injuring 24. Heard on the Cockpit Voice Recorder (CVR) was the last words of the native Chinese speaking pilot who said, “What does ‘Pull-up, pull-up” mean?” It is almost impossible to believe that there should be such lack of knowledge of audio warnings, especially to anyone outside of aviation.

Sources of Errors

The sources of communication error:

  1. Phonology – language sound patterns, prosody, e.g. speech rate, stress, intonation, pauses.
  2. Syntax – language word patterns, sentence structure.
  3. Semantics – language ‘meaning patterns’.
  4. Pragmatics – language in context, situational influences on meaning.

Considering numbers in voice communication conventional wisdom would say that as the digits are particularly standardized there should be little difficulty with regional language barriers. However, that assumption proves to be incorrect. Dr. Bürki-Cohen (Bürki-Cohen, 1995) researched the particulars of how complexity affects pilot recall. ATC normally are required to state digits individually, such as an altitude of 17,000 has to be stated as “one seven thousand.” ATC regulations allow controllers to add grouped digits after the individual digits were stated, i.e. “one seven thousand, seventeen thousand.” It was believed that this would aid retention and accuracy. However the research showed there was little difference with or without grouped digits added. Indeed, analysis showed an advantage of the restated format over the grouped format at higher complexity levels. It is axiomatic that increasingly complex verbal instructions carry a commensurate increase in the risk of misunderstanding.


If it is hoped to reduce the human factors accident rate more attention needs to be paid to language. The higher standard to which the international aviation community should aspire must constantly strive to ensure that the recommendations of ICAO in the area of English Language Proficiency should be achieved.


The following recommendations are suggested:

  1. Establish accredited schools for teaching English to all in aviation,
  2. Set clearer standards for testing and awarding all levels of proficiency,
  3. Research current “standard” phraseology, particularly differences between native English speaking nations, to harmonize those standards, reduce or eliminate ambiguity – particularly where cultural influences effect the use of language,
  4. Study pronunciation, and publish standard pronunciation for those words which exist in standard phraseology.


AC 60-28 CHG 1 Appendix 1


The following English language proficiency standards* must be met by the applicant and evaluated by the designated examiner or aviation safety inspector (ASI) when determining if the applicant meets the English language eligibility requirements of 14 CFR parts 61 and 63:

1.            PRONUNCIATION. Assumes that English is not the applicant’s first language and that the applicant has a dialect or accent that is intelligible to the aeronautical community. Pronunciation, stress, rhythm, and intonation are influenced by the applicant’s first language, but only sometimes interfere with ease of understanding.

2.            STRUCTURE. Relevant grammatical structures and sentence patterns are determined by language functions appropriate to the task. Basic grammatical structures and sentence patterns are used creatively and are usually well controlled by the applicant. Errors may occur, particularly in unusual or unexpected circumstances, but rarely interfere with meaning.

3.            VOCABULARY. The applicant’s vocabulary range and accuracy are usually sufficient to communicate effectively on common, concrete, and work-related topics. The applicant can often paraphrase successfully when lacking vocabulary in unusual or unexpected circumstances.

4.            FLUENCY. The applicant produces stretches of language at an appropriate tempo. There may be occasional loss of fluency on transition from rehearsed or formulaic speech to spontaneous interaction, but this does not prevent effective communication. The applicant can make limited use of discourse markers or connectors. Fillers are not distracting.

5.            COMPREHENSION. Comprehension by the applicant is mostly accurate on common, concrete, and work-related topics when the dialect, accent, or variety used is sufficiently intelligible. When the applicant is confronted with a linguistic or situational complication or an unexpected turn of events, comprehension may be slower or require clarification strategies.

6.            INTERACTIONS. Responses by the applicant are usually immediate, appropriate, and informative. The applicant initiates and maintains exchanges even when dealing with an unexpected turn of events. The applicant deals adequately with apparent misunderstandings by checking, confirming, or clarifying.

* Level 4 Rating Scale adopted from the ICAO Language Proficiency Rating Scale found in ICAO Document 9835 and the attachment in ICAO Annex 1.


Manual on the Implementation of the ICAO Language Proficiency Requirements – Doc 9835-AN/453

World Englishes, Vol. 23, No. 3, pp. 451–470, 2004. 0883–2919 Fatal miscommunication: English in aviation safety ATSUSHI TAJIMA

The challenge of regional accents for aviation English language proficiency standards: A study of difficulties in understanding in air traffic control–pilot communications. T. Tiewtrakul and S.R. Fletcher Ergonomics Vol. 53, No. 2, February 2010, 229–239

A survey of aviation English tests J. Charles Alderson, Language Testing 27(1) 51–72 2010 DOI: 10.1177/0265532209347196

An Analysis of Tower (Ground) Controller-Pilot Voice Communications. Final Report No. DOT-VNTSC-FAA-95-41

Bürki-Cohen, J. (1995). Say Again? How Complexity and Format of Air Traffic Control Instructions Affect Pilot Recall. In 40th Annual Air Traffic Control Association Proceedings, September 1995, 225-229.

Bürki-Cohen, J. (2003). Evidence for the Need of Realistic Radio Communications for Airline Pilot Simulator Training and Evaluation. In Proceedings of the International Conference Simulation of the Environment, Royal Aeronautical Society, 5-6 November, London, UK.

AC 60-28, English Language Skill Standards

Crew Resource Management            Date: 1/22/04            AC No: 120-51E TRAINING$FILE/AC120-51e.pdf



Do Pilots join associations? HAI, NEMSPA, AOPA


Here’s a question for all pilots, do you join associations, societies, or any aviation communities? A gut feeling tells me the answer is no! We live and work in a tiny little office, otherwise called a cockpit, for good reasons. There’s many a pilot who has said, either out loud or to himself, “I’m glad to get airborne to get away from the BS on the ground!”

“So what?”, I hear you cry. Well, there are some advantages to joining those organizations who represent us. Three in particular spring to mind, in no particular order:

Helicopter Association International

The first meeting of the founding members of this group took place on December 13th 1948. Yes, younger readers, there were helicopters way back then. Going through several name changes, the mission of the HAI has remained largely the same over more than 60 years. Their mission statement; “To provide its members with services that directly benefit their operations, and to advance the international helicopter community by providing programs that enhance safety, encourage professionalism and economic viability while promoting the unique contributions vertical flight offers society.”

You may join the HAI by clicking here.

National EMS Pilots Association

Whilst HAI serves the entire helicopter community world-wide, NEMSAP represents the EMS pilot in the USA. Much more specific and focused on issues that effect the American EMS pilot’s life. From personal experience, I know that NEMSPA has been very influential with those people who regulate us! It is clear that their efforts have prevented overbearing regulation, have created an influential voice for us all at Washington, DC, and are actively pursuing leading-edge research into issues that effect us all. Their mission statement; “We, the National EMS Pilots Association, will strive to help the Air Medical industry prosper safely and enhance the delivery of pre-hospital health care. We will provide the leadership necessary to establish standards of operational safety and a forum for the dissemination of knowledge. This organization will continue to be a major advocate for positive change for our industry.”

You may join by clicking here.

Aircraft Owners and Pilots Association

Incorporated on May 15th 1939, AOPA represents over 400,000 members. Their advocacy and campaigning efforts with the nation’s lawmakers and regulators have helped to prevent aviation hostile political people from closing us down, closing our airports, and from unfairly taxing us out of existence. The contribute greatly to aviation safety through their Air Safety Foundation, and rely on general aviation’s support through their Foundation.

AOPA’s mission statement; “We preserve the freedom to fly by…

advocating on behalf of our members,
educating pilots, nonpilots, and policy makers alike,
supporting activities that ensure the long-term health of General Aviation,
fighting to keep General Aviation accessible to all, and
securing sufficient resources to ensure our success.”

AOPA’s vision statement; “AOPA is the beacon for those who cherish the freedom to fly. It demonstrates what is possible when a determined organization listens to its members, collaborates with its colleagues, finds solutions with its partners in government, and focuses its resources—all to secure the future of General Aviation. AOPA’s success is proof that the public good can be served while individual freedoms are preserved.”

You may join by clicking here.

NEMSPA Pilots Survey of America’s Heliports

NEMSPA Pilots Survey of America’s Heliports
Now Available for Review and Download

NEMSPA has completed the intiial analysis of the data gathered from a survey of helicopter pilots nationwide. The survey garnered over 1300 responses from helicopter pilots with opinions and suggestions regarding the design and the safety of the heliport facilities that they typically use in their daily flying duties. The detailed results of the survey can be accessed by Clicking Here

Helicopter makes emergency landing in Palo Alto – AP State Wire News – The Sacramento Bee

If ever you’ve been involved in an emergency, be aware that within minutes you can expect a large number of reports. Check out this Google Search for the 40 news stories about this Robinson R22 forced landing.

Helicopter makes emergency landing in Palo Alto – AP State Wire News – The Sacramento Bee.


Bell Helicopter loses patent lawsuit | Airlines and Aviation | Dallas Business, Texas Bu…

Bell Helicopter loses patent lawsuit | Airlines and Aviation | Dallas Business, Texas Bu….

Helicopter pilot misjudged altitude: report

Helicopter pilot misjudged altitude: report.

Rochester Wings 2012

May I recommend this year’s recurring annual event, Rochester Wings 2012.

Helicopter AND Fixed Wing


After posting some fixed wing articles, and having a fixed wing operation at my place of work, I have tweaked the descriptions on pages and categories on this blog. It is a fact that there are a lot of EMS fixed wing flights every day, from ordinary airliners doing “Lifeguard” status flights to air ambulance specific aircraft flying patients to hospitals all over the world.

It would be quite fascinating to discover how many patients are flown!

English: Fixed-wing aircraft in the sky

Image via Wikipedia